0001209191-19-006513.txt : 20190201
0001209191-19-006513.hdr.sgml : 20190201
20190201171008
ACCESSION NUMBER: 0001209191-19-006513
CONFORMED SUBMISSION TYPE: 5
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20161231
FILED AS OF DATE: 20190201
DATE AS OF CHANGE: 20190201
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Fontenot Teri G.
CENTRAL INDEX KEY: 0001661066
FILING VALUES:
FORM TYPE: 5
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-12251
FILM NUMBER: 19560662
MAIL ADDRESS:
STREET 1: 18933 EAST PINNACLE CIRCLE
CITY: BATON ROUGE
STATE: LA
ZIP: 70634
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: AMERISAFE INC
CENTRAL INDEX KEY: 0001018979
STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331]
IRS NUMBER: 752069407
STATE OF INCORPORATION: TX
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 2301 HIGHWAY 190 WEST
CITY: DERIDDER
STATE: LA
ZIP: 70634
BUSINESS PHONE: 337-463-9052
MAIL ADDRESS:
STREET 1: 2301 HIGHWAY 190 WEST
CITY: DERIDDER
STATE: LA
ZIP: 70634
5
1
doc5.xml
FORM 5 SUBMISSION
X0306
5
2016-12-31
0
0
0
0001018979
AMERISAFE INC
AMSF
0001661066
Fontenot Teri G.
18933 EAST PINNACLE CIRCLE
BATON ROUGE
LA
70810
1
0
0
0
Common Stock, par value $0.01
2016-09-23
5
L
0
L
1.18
57.52
A
1074.18
D
Common stock, par value $0.01
2016-12-29
5
L
0
L
20.58
62.85
A
1094.76
D
The Reporting Person was appointed to the Board of Directors of the Company in January 2016. The Reporting Person placed the shares in a brokerage account with a pre-existing dividend reimbursement plan. Pursuant to this dividend reinvestment plan, the Reporting Person acquired a total of 21.76 shares of Common Stock at a purchase price of $1361.40 during 2016. Reporting of the purchase of these shares was exempt under Rule 16a-6. However, these purchases should have been reported on a Form 5 on or before February 14, 2017.
/s/Teri G. Fontenot
2019-02-01